Peaceful death has been a simple wish of the people since ancient times,and palliative care can help dying patients realize their wishes and improve the quality of life.Medical staff found the palliative needs of patients in clinical practice,"There are so many end-stage patients who need help,so it is necessary to carry out palliative care"(field notes),thus generating the motivation to learn palliative care。

the medical staff of the center and the medical association believe that in addition to saving lives and injuries,helping patients die peacefully is also their mission As medical workers."as a doctor and a hospital administrator,we have the right and responsibility to help everyone die with dignity and peace,which is our goal"(Field Notes)。

Early mutual understanding laid the foundation for formal cooperation.Among all the cooperative units,some managers and center directors have common learning experience,some have studied the relevant courses of Peking Union Medical College Hospital,and some directors have actively contacted and cooperated,gradually developing support groups,professional training and other forms of cooperation,which has contributed to the formation of the Medical Association of Palliative Medicine Specialties。

the discipline construction of palliative care In China is still in its infancy,and most of the workers are halfway out,with different disciplinary backgrounds.in the face of complex symptom management,workers should keep learning and supplement clinical experience^[8]。 "Tranquilization and palliation are suitable for the second direction of study,and cancer is the most suitable,because patients with end-stage cancer are the most common..When you encounter a situation that you don't understand,consult a specialist,keep learning,at least guide the patient to a professional department to solve the pain..I will learn something for the patient and learn to use new drugs"(field notes)。

Dying patients often suffer at the psychological and spiritual levels,which cannot Be quantified and require workers to have sensitive perception to detect and evaluate."I think this is the point of the tranquil man,his perception of the suffering of the patient.".Because we go to the patients and the families,we can feel their pain.be sensitive to this,and then do some further excavation and empathy(N1 interview)。

In the initial practice of hospice palliative care,workers tend to set higher professional standards,which brings high expectations,and unmet expectations may lead to job burnout.In the face of job burnout,workers will experience a series of loss and reflection processes.These experiences encourage them to reconcile with themselves,reduce their inner consumption,and more clearly realize the meaning and value of their work.At first,we always said whether This case was successful or not.Now we don't worry about it.that's your own definition.you always think That life and death are both peaceful,which is successful.How can there be so many successes and failures?Then you will die if you come.will you not succeed?I accompanied my daughter and accompanied him to do the funeral.this is a success,and I will not be entangled when it is over.(N3 interview)。

In order to help patients and their families relieve their pain,workers will deeply understand their family and social relations and empathize with each other's feelings.Sometimes this empathy will form a tension with the workers'own values,which will wear down their work energy and enthusiasm.the quality of non-judgment enables workers to identify the differences between others and their own ideas,avoid their own inner conflicts,and maintain a peaceful mind."I think We are doing more and more now,so We don't judge.We used to judge.How can this family be like this?But it's just our own people talking about it.we try not to bring it to the patients.We used to bring it to the patients."(N3 interview)。

in the palliative medicine center,doctors,nurses and Social workers form a solid iron triangle working model.the external personnel of the center(such as volunteers)are unstable,but the working roles of doctors,nurses and social workers are always stable:the director(doctor)controls the overall situation,formulates development goals,assigns tasks,and follows up the progress of tasks;the head nurse cooperates with the director to carry out the work at the medical,administrative and management levels,organize the nursing team,and is responsible for external training;social workers are mainly responsible for the management and logistics of volunteer organizations.the three cooperate with each other to understand each other's abilities,temperaments and dispositions,and to achieve profound trust.Together,they create an open and warm team atmosphere(Fig.2)."for example,for some special patients,we will set up a group,and then bring in the directors,especially those who set up a group in the early stage,that is,for some difficult or unmanageable symptoms,we communicate directly in the group,which is also a support for the team"(N4 interview)。

Before the establishment of the center,the purpose of the work of the director and the head nurse was very clear,"(1)to help medical staff,improve doctor-patient relationship,and promote mutual trust and understanding between the two sides;"(2)to help hospitals improve service quality,create a brand of humanistic care,and create a warm image of hospitals;(3)it is to help Patients and their families,relieve pain and get peace"(Field Notes).After defining the goal,we can concentrate on promoting the work.patients'recognition of Concord brand and trust in medical staff constitute the internal driving force for workers to persist in development."After knowing the patient's condition,the director connected the video dialed by her husband,and saw that the patient was conscious and even smiling.".Speaking of"I hope to entrust my last days to Concord",the husband bowed his head and endured his grief,and the director's eyes were red when he saw It"(field notes)。

Many workers are self-traumatized,some can not bear to see the pain of patients before death,some have deep anxiety and fear of death in their hearts,they find palliative care for different reasons,hoping to alleviate the pain."the average hospitalization rate on our side is about half a year,so I want to redeem myself in the process of confusion..I want to see if someone can survive in addition to this state.".What I mean by survival is that our medical staff can also survive very well,and I want to see how they do it"(N1 interview)。

the hospice palliation practice In Peking Union Medical College Hospital began in the oncology ward.in 2012,the director and the head nurse went to Taiwan to study.After returning,they first tried in the oncology ward.the head nurse contacted the volunteer organization of Peking Union Medical College to provide caring companionship for patients on a regular basis.the ward's attempt has achieved remarkable results."in about three years,the atmosphere of our ward has undergone a complete qualitative change,from a negative channel to a positive channel.Although everyone is still very busy,the state of the people working there will change,and they will no longer feel that I want to escape from this place all the time"(N1 interview)。

after accumulating practical experience,the director set up a working group on hospice palliative care and started the consultation work of the whole hospital.During the consultation process,the director will confirm the needs of the treatment team of the original department and the patients and their families,act as a communication bridge between the two sides,help patients make appropriate medical decisions,and teach the treatment team of the original department symptom management experience and communication skills.the work of the center has gradually attracted the attention of all sectors of society.During the investigation,the researcher went through multiple social media shoots.In addition,volunteer organizations have gradually expanded,and volunteers have brought their work experience back to their areas,which has led to the development of local hospice volunteer services."It's also a copy.They(volunteers)take things back After learning,which can drive the development of a region"(S3 interview)。

palliative medicine Curriculum:When the Working Group on hospice palliative care was established,it emphasized the"Concord Model,Education First".the director has set up a Palliative Medicine course for medical students to let more medical students know about tranquility and palliation.According to D1,although"front-line doctors sometimes cannot control the treatment decisions of their superior doctors,they can recommend consultation to gradually expand the influence of Hospice Palliative care,so that patients can receive better care and treatment"(collecting data in kind)。

medical consortium training:the training is mainly based on regular ward rounds.in addition,when the Medical consortium unit encounters various emergency problems In the process of care,such as the rapid change of the patient's condition,the treatment team can contact the center personnel at any time to arrange online ward rounds。

training plan:Under the joint promotion of the Center staff and the leaders of the Institute,the center formally recruited the first Training team in June 2023.the trainees are fully involved in the work of the center,learning and experiencing peace and relaxation through practice.Sometimes you really can't say it very clearly in words.but anyway,in their place(Palliative Medicine center),I think the most impressive thing is that they respect patients very much,let them express more and make decisions for themselves,But now we basically do not have this..His way of treating patients can be applied to(our)clinical practice"(N2 interview)."。

Dandelion Plan:in 2022,with the support of the charity fund,Peking Union Medical College Hospital will take the lead in implementing the Dandelion Plan.Every year,one province or region will be selected to provide key assistance,and the staff of the center will personally visit and teach to lead the construction of hospice care in the whole province.Up to now,he has led the hospice care work in three provinces and cities and carried out a series of training seminars。

consultation:There are two main purposes of in-hospital Consultation:(1)to help Patients relieve pain and connect resources;(2)Respond to the needs of the original department,act as a bridge to help both doctors and patients communicate,inform the adverse outcome,and talk about the aftermath.patients often say,"I feel better when I see you(the staff of the center)"(field notes)。

outpatient service:In February 2022,The hospice palliative care clinic was officially established,including medical outpatient service and joint outpatient service.Before The opening of each outpatient clinic,the follow-up nurse contacts the patient or family members through the contact information In the registration information to confirm whether the registered person has the need for peace and relaxation.In the joint outpatient clinic,nurses carry out wound care,daily maintenance of venous catheters and other nursing operations for Patients,and carry out health education.the symptom management of terminal patients is more complicated.the center has prepared a series of brochures and small Notes,including medication guidance,grief counseling,body donation process,living will manual,etc.,for family members to read.patients often say,"Your clinic is really good,otherwise we really don't know what to do about it."(Field notes)。

medical consortium referral:There are 7 medical consortium units,which is a multi-level joint system.the center uses this platform to explore the three-level referral system of general hospital,secondary hospital and community home,and to provide multi-dimensional care for patients and their families.in addition to multi-dimensional referral,some secondary hospitals also undertake local hospice care guidance work,"linking a number of community health service centers and pension institutions at the lower level,and establishing a guidance center for the combination of health and medical care for the elderly"(collecting data In kind)。

Anning co-management mode:Peking Union Medical College hospital has not opened an hospice palliative ward for the time being.in 2023,the center jointly opened an Anning co-management bed with other departments in the hospital to provide co-management care for patients with hospice care needs in the hospital.the staff of the center hand over their shifts early every day to ensure the quality of co-management。

In the Early stage of hospice palliative care in Peking Union Medical College Hospital,hospice care in China is still in its infancy and needs extensive social publicity.early volunteers also participated in advocacy work in addition to clinical accompaniment.At present,the volunteer organization has a relatively mature organizational structure.in addition to social publicity,it also has the tasks of auxiliary teaching and literature tracking,and each group performs its own duties(Figure 3)。

there are two main reasons for the over-saturation of workload,which is reflected in almost all the workers in the center and the Medical Association:(1)too much energy and time are invested in caring for patients:end-stage patients suffer from multiple levels of pain,and symptom Management requires repeated assessment by medical staff and continuous revision of treatment plans;for psychological,spiritual and other deep-seated pain,the medical association ward has carried out many special projects,such as aromatherapy,music therapy,etc.Behind each service is frequent doctor-patient communication,which often occupies the time of recording documents and administrative management."the director had already seen three patients,and the head nurse finished the first nursing clinic for two hours.".When she left,she kept telling her family members the key points of wound care(field notes).(2)Shortage of staff:According to the Basic Standards and management Standards for hospice care centers(Trial)issued by the National Health Commission in 2017,Hospice care Centers should have at least 50 beds,but There are not enough workers to match them^[9]。 In reality,There is even a situation where one team manages two wards.However,there is no targeted performance appraisal for tranquility and relaxation,and it is difficult to attract more medical staff with low salaries.and it depends on the ratio of your beds.there are too many conditions for assessment.the whole hospital knows that the oncology department is the most tired,and Anning is the most tired.But relatively speaking,your mortality rate is also the highest,and the higher your mortality rate,the lower your performance..We hold activities for patients completely free of charge"(N4 interview)."。

Due to the unclear performance appraisal system,the income of the center and ward is low,and the activities related to tranquility and mitigation are diverse and need sustained and substantial financial support,but at present,the funding they receive can not cover the related expenditure."the center is supported by three charitable funds at the same time..but the director says they can only cover one third of the total expenditure"(Field Notes)。

some of The units of Peking Union Medical College Hospital and Medical Association have received financial support from the government,and have set up rooms,activity rooms and other places in accordance with national standards.There are also Some hospitals whose ward environment keeps its original appearance and lacks activity Field."in the wards of Union Medical College Hospital,except for the International Department and a few departments,most departments do not have private places such as conversation rooms and tea rooms.When communicating with family members alone,they often stand in the corridor and talk for tens of minutes,and may be interrupted by others.".the center had envisaged applying for an office as a place for talks,but for various reasons it failed to do so"(field Notes)."。

hospice palliative care requires multidisciplinary collaboration to provide comprehensive care for patients.After returning from studying in Taiwan in 2021,The center team sought partners in the hospital who agreed with the concept of hospice and explored the hospice palliative care model together.the director said that her colleagues were enthusiastic about helping her,and her colleagues said to her:I have been in Concord for so many years,and I know how difficult it is to do one thing.At this point,her eyes were red again.(Field Notes)。

the center led the Medical Association to call for the improvement of the salary system,hoping that the new system can be introduced and implemented to solve the current shortage of talents and the over-saturation of workload."I would like to appeal for a salary adjustment,or a corresponding charge for hospice care,but the charge should not be too high,and should reflect our value"(N1 interview)。

In order to meet the diverse needs of patients,the working methods of the center have been adjusted to meet the diverse needs of patients.we are constantly groping,and we are changing very fast.In this year,we did not have outpatient service at first,and then we began to go out of the outpatient service…Our way of working has to be constantly adjusted"(N1 interview)。

Palliative medicine helps patients and their families to face life and death calmly,and also increases The sense of benefit and achievement of caregivers.the concept of tranquility also permeates their lives and affects their way of doing things."My personality is relatively calm now.I used to be a very irritable person.Although I have some emotions when things happen now,I really digest them very quickly,because I think no matter how big things are,they are not worth life and death"(S1 interview)。

After years of consultation,other departments in the hospital learned about palliative care,and the medical staff gradually recognized the concept of palliative care,and many people joined in and tried different treatment options with palliative medicine.For example,in the hemodialysis room,"hemodialysis patients often have skin itching and other discomforts.Originally,doctors and nurses thought that this was normal,but now they began to pay attention to symptom management and began to try medication"(field notes)。

Tranquil palliation is to relieve The pain of patients,help their families through grief,and provide them with all-round care,and they are the most direct beneficiaries.the duration of outpatient and consultation in hospice palliative care is 30 to 70 minutes,and long-term communication has established a close doctor-patient relationship.As a family member,I feel too warm.That warmth will directly make you feel less anxious and irritable(S2 interview)。